CABG

(Ver. 25/JAN/2015)

Before procedure
- Head light battery charging
- Check Warm N/S, cold N/S
- Turn on EVH system, flow meter
- Plastic bags for gauze count
- Suction, CO2 power check

Anesthesia: General Endotracheal Anesthesia

Position: Supine position
TEE probe insertion
Skin preparation: betadine soap, duraprep
Surgical drape: Universal drape
Medical equipment: ERBE 2ea, flow meter, blower, EVH system, DF

Set
OHS set, wire set, hemoclip applier set, sternal retractor, OHS micro
instrument set,
rultract retractor, stryker saw
Extra
Scope (7mm 0), light cable, CO2 line, cross clamp, bulldog clamp 5, intra
DF
Prn) blunt self-retractor, seeker, blunt nerve hook, pericardium retractor
Supplies
Pitcher2, puspan6, big tray, blue towel, white towel, 4x8 gz, 4x4 gz,
packing gz, foley cath., urine bag, glove, gown, suction line, camera drape
2, skin stapler, skin marker, EB 2, IOBAN, light handle, enema syringe 2,
30cc syringe 2, 10cc syringe 3, 1cc syringe, blunt needle 2(for papaverine
soaking), #10/11/15 mess, bovie2, bovie tip(blunt short, medium, long),
bovie cleaner, needle counter2, tourniquet kit2, coronary marker,
hemoclip(blue, yellow, micro), bone wax, nylon tape, suture boots, cross
clamp boots, 28cvd/32st chest cath., chest bottle(dual), blower, 4.0,
4.5punch, lancet, flowmeter 2/3mm, vein pressure tip
Prn) snare kit, beaver knife, 28 st chest cath.&chest bottle(single)(in case
of, pleura open), pace maker wire, alligator line, flowmeter 4mm, air
suture, octopus, surgi-loop (in case of, open saphenous vein surgery)
Drug
500cc NS + papaverine 7ampules + 5,000 units heparin 0.3CC
Surgicel, tisseel2
(Prn) spongostan, nu-knit, surgical fibrilla
Suture
Pledget(PCP50), 1/0vicryl CR(VCP752D), 2/0ethibond(6987) X2,
3/0ethibond(-----) X2,
4/0 prolene(8761) X6, 5/0 prolene(8556) X2, 6/0prolene(8706) X3, 7/0

prolene(8704) X2, 8/0 prolene(2777) X2, 1 black silk tie(W215), 3/0 black
silk tie(202)X2, 0 vicryl(VCP352) X2, 3/0 vicryl(VCP242) X2, sternum
wire(650) X2
Dressing
mepilex border, 4x4gz and medifix apply, Opsite.
Procedure
1. Skin incision
- #10 blade, bovie, army navy
Surgery starts with 2 cm Vertical incision from Manubrial fossa to xyphoid process deepen
until the subcutaneous & fascial layer with cautery dissection (Coag 80-100). After the
Xyphoid process division, they sometimes use sponge-stick (long Kelly with cherry) for blunt
dissection of substernal area.
2. Median sternotomy
- Stryker saw, bone wax with 4x4gz
The 1st assist uses Army-navy to retract the uppermost incision, while the surgeon use
Stryker sternal saw for sternotomy while anesthesia makes the Lung down to prevent pleural
tear. After sternotomy 1st assist use 2 Army-navy ret. for unilateral hemi sternum retraction,
checking for sternal bleeding (bone wax for surgeon on 4x4 gauze) if incidental Innominate
vein injury happen, Surgeon and 1st assist may change places to address the bleeding by
using electrocautery.
3. Preparation of graft internal thoracic artery harvest
- For LIMA ret. they will put spongostan+surgicell on the teeth of the rultract.
- they will use ring fcp, debakey fcp, coronary metzenbaum, hemoclip applier(mini, S, M).
Prepare the following in the LIMA mayo table.. papaverine sol, bulldog, 4x8gz, packing gauze.
*Prior to procedure, remember to attach the Rultract Holder on the bed.
4. SVG harvest (Open Version)
Prepare - #10 blade, bovie, cvd. mosquito, blunt self ret, hemoclip (S,M), right angle, #11
blade.
On Tibial medial condyl and 2-FB medial point use #10 blade for incision. And cautery for
Skin and subcutaneous bleeding control, use blunt weitlaner ret. to retract, use Cvd.
Mosquito for dissection, until they find the SVG isolate with mixter then tagged with surgical
loop. Vein branch use clip for ligation, ordinary metzenbaum cutting.
For Proximal vein harvest they will use Rt. Angle clamp, tie with mersilk 3/0 then a horizon
ligating clip to secure then #11 blade to cut.
A titus needle will be placed in the distal part of the vein, then tie with mersilk 3/0, then
connect to 30cc syringe with heparinized solution, priming the SVG to check on leakage then
checked with mosquito (mogi) then securing it with horizon clip (S,M).
5. Endoscopic Saphenous Vein harvest
On Tibia medial condyle and 2-FB medial point, using #10 blade, make a 1.5~2cm incision
up to subcutaneous. Mosquito curve will be used for dissection until SVG was exposed.

EVH trocar insertion, secured by inflating air balloon with 15~20cc air. Trocar will be
blocked with 5cc syringe to clog the carbon dioxide insufflation then superficial vein
dissection starts.
Using a 5mm 0 degree Scope and dissector, SVG course will be taken to isolate the graft
from distal to proximal approach. During vein dissection, PA should leave at least 5mm
allowance when cauterizing to give room for repair.
After isolating the circumference of the vein through dissection, the dissector will be
removed. A specialized cautery device/scissor branch coagulation/cutting will be inserted, for
Proximal dissection use #11 blade incision, mosquito curved to find the vein, tie with
Mersilk 3/0, then cut, then horizon M clip on end of the tie. Skin stapler will be use to close
all the incision. But sometimes they use 3/0 (Ethilon) nylon to close.
6. Exposure of the heart
Sternal edge will be draped with 4x8 gauze soaked in 10% betadine and then a white towel
to cover the site. Sternal ret. applied, Debakey blunt to Surgeon and 1st assist to hold the
thymus, cautery to the surgeon for thymectomy.

To open the Pericardium give DeBakey forceps to surgeon and 1st assist for retraction and
then surgeon will cauterize the pericardium to open in inverted T passion.
During exposure of the blunt debakey will be used for heart Protection. The 2 nd assist will use
Yankauer tip for effusion suction. Vicryl CR 1/0 for tenting then Kelly traction, by clamping
on the towel.
Arterial cannulation
7. Dissection around the aorta
During application of Cross Clamp, 1st assist will use 4x8 gauze to traction the aorta to give a
visible view to the surgeon for clamping.
8. Aortic cannula suture
2/0 Ethibond single arm (Forward load) -> cut with metz then squeegee then secured with
mosquito. (Single load only)
2/0 Ethibond double arm (Forward-Forward Load) ->cut with metz then squeegee then
secured with mosquito. (Double load)
Single two staged venous cannulation
9. Right atrial cannula suture
Prolene 4/0 (Forward-Forward Load) -> slider-> cut scs. -> mosquito
On RA auricle Prolene 4-0 purse-string suture, 1st assist with DeBakey forcep traction, 2nd
assist cut with metzenbaum then 1st assist slide-down.
10. Aortic root cannula suture

Prolene 4/0 (Forward-Forward) + pledget + counter pledget -> slider -> cut scs. -> mosquito
Aortic Cross Clamp Prolene 4-0 pledget simple suture counter
pledget suture 2 metzenbaum needles cut 1 slide-down.

11. Retrograde cannula suture

On Mid-atrium using Prolene 4-0 for purse-string suture 2nd assist cut with metzenbaum then
1st assist slide-down.
12. Aortic cannulation
Aorta adventitia, surgeon will cauterize it and trim down the layer with metzenbaum to strip
the site, with Purse-string sutures in place, surgeon will use #15 blade to stab the aorta and
make opening. Surgeon holds DeBakey forceps on the other arm to prevent splashing of
blood. Then aortic cannula insertion, squeegee then lock with mosquito. A Mersilk 1 strand
(2x) will be used to secure aortic cannula. CPB line will be connected to the aortic cannula.
Then make a rolled towel with towel clip, to pillow the Aortic cannula.
Single two staged cannulation
13. Right atrial cannulation
1st assist with DeBakey forceps to grip RA auricle, Surgeon use metzenbaum to cut and
spread the RA auricle then dual-stage cannula insertion. Enema syringe to prime the cannula
before connecting to CPB. Squeegee locked with mosquito then tied with Mersilk 1.
CPB ON
14. Cardioplegia management set fix
Cardioplegia solution line will be primed and secured in the head part then clamped.
15. Root cannulation
Aorta adventitia will be dissected with cautery or metzenbaum to strip the root (single lumen)
aortic root will be pierced and then secured with prolene 4-0 with pledget then counter
pledget. Squeegee then lock with mosquito. Root will be connected to red button line.
16. Retro cannulation
After purse-string, Surgeon will use #11 blade for incision, then tonsil forceps (lejunne) to
spread, then insertion of retrograde cannula. Stylet removal then mersilk tie 1 loaded at long
Kelly then connect to pressure line blue.
17. Myocardial protection
topical cooling, iced-saline irrigation. Cardioplegic solution infusion
- Antegrade
cold blood cardioplegia infuse repeated every 10~15min. during the cross clamp time.
After distal anastomosis additional cardioplegia will be infused to the vein graft.
- Retrograde cardioplegic perfusion
2 function:
Delivers Cardioplegia on the retrospective part.

For deairing and removal of emboli.

Graft anastomosis
18. Arteriotomy
Midline of the coronary artery posterior wall injury prevention : angle of blade 45 beaver
blade
Enlarged to a length : 5~7mm incision
Calcified arterial wall : removing a triangular segment
Distal obstructive plaque: enlarging an arteriotomy across obstructive plaque
intimal injury : not to force too large probe
#15 blade incision (beaver blade???) potts scissors calibrating the lumen with a probe
While the 2nd assist use the blower mister to provide clear view of the site.
19. Distal anastomosis
Distal end of the conduit : oblique, hood-shaped lumen, >25% arteriotomy opening.
Distal anastomsis : Prolene 7/0 ( SVG )-FF??, Prolene 8/0 (LIMA)FF?? double arms tapered
needles.
papaverine solution will be intermittently sprayed by 2 nd assist.
Clear view blower by assist to provide clear view and make the anastomosis time in minimum
and fast also to make intima vessel not dry.
Stepwise technique ????
first needle-outside-surgeons side of the heel - inside outside inside four rounds
pulling of suture in seesaw manner
4/3 suture reprobing lumen, posterior wall check.
suture 2 metzenbaum needle cut.
tie Retrograde CPS infusion & CPS infusion via graft - 5mm cutting.
20. Proximal anastomosis
Position: LAD, DIA at the 2 oclock
Ramus, OM horizontally at the 3 oclock
PDA at the 8 oclock
Aorta adventitia using metzenbaum to strip, using lancet to make stab wound then use
mosquito curve to spread 4.0 mm disposable puncher to make opening then use prolene
6-0 suture. Second assist will use cherry stick (cherry on long Kelly (Pean) cvd to retract the
RA Auricle to provide clear view of the anastomosis site.
21. Retrograde CPS cannula removal before proximal anastomosis
Re-enforcement suture with 4-0 Prolene
Completion of the CPB bypass
22. Aorta Cross Clamp OFF
Root vent, LA vent stop, Ambu bagging, ACC release
23. Y graft formation
SVG bulldog clamp*2 - beaver blade potts scissor- Prolene 7/0 continuous suture while
2nd assist use Clear view blower mister.
Graft Deairing with 26g needle
24. TTFM(transit-time flow measurement), TEE examination
3mm, 2mm, 4mm(optional)

CPB weaning
25. Decannulation
1 Root cannula removal
2 Venous cannula decannulation & re-enforcement suture with 4-0 Prolene
3 After Protamine infusion, Aortic cannula decannulation, bleeding control by reinforcing
with Ethibond 2/0 with counter pledget suture
remnant volume infusion. ????
26. PM wire insertion
ventricle insertion 2nd assist use scissors to cut needles. skin stay suture with Ethibond
3/0.
27. Hemostasis
Surgicel, emistat, proximal anastomosis site- coronary marker, Tisseal
28. Chest tube insertion
Pericardial tube 28Fr. angled
Mediastinal tube 32Fr. st
Pleura open thoracic tube 28 Fr. st (optional)
Surgeon incise with #10 blade and use cautery for Bleeding control. Stay sutre: : ethibond
2/0 purse-string suture, needle cut & make knot and mosquito curclampping. ???
Sing stay suture tie, chest tube tagging . Hemostate tunnel 1st assist
chest tube hemostate tip . stay tagging, chest tube tip cut.
29. Bleeding control & Pericardial cavity irrigation
30. Pericardial closure with Repel CV Prolene 4/0 interrupt suture
31. Sternal wiring
Steel wire stenum proximal suture. 1st assist army navy ret. traction & expose .
Suture wire cutter needles cut kelly wire clamping 3~4 twist.
Wiring army navy ret. sternum traction wire suture site bleeding &
coagulation.
32. Sternal closure
Gauze count wire X . sternum closure, operator
wire twist . 1st assist twist wire operator wire cutter 2
cut, 1st assist wire amynavy ret. traction. surgeon wire
holder . Sternum 90 mallet hitting.
33. Skin closure in layers
Fascia : V/C 0 continuous suture
subcutaneous : V/C 3-0 continuous suture
Fascia subcutaneous fatty irrigation
Baro-vac insertion, nylone 3/0 skin stay suture.
skin : stapler
34. Aseptic occlusive dressing

Opsite / Sorbact dressing